Elective segmental ureterectomy for transitional cell carcinoma of the ureter: long-term follow-up in a series of 73 patients.

UNLABELLED: What's known on the subject? and What does the study add? Upper Urinary Tract (UUT) Transitional Cell Carcinoma (TCC) is an uncommon disease and represents approximately 5% of all urothelial carcinomas. We report our series on 73 patients treated with Kidney Sparing Surgery for UUT TCC. Good results have been achieved in terms of oncological outcome comparing this conservative approach to the radical nephrourectomy. OBJECTIVES: • To report the long-term oncological outcome in patients with transitional cell carcinoma of the ureter electively treated with kidney-sparing surgery. • To compare our data with the few series reported in the literature. PATIENTS AND METHODS: • We considered 73 patients with transitional cell carcinoma of the distal ureter treated in five Italian Departments of Urology. • The following surgeries were carried out: 38 reimplantations on psoas hitch bladder (52%), 21 end-to-end anastomoses (28.8%), 11 direct ureterocystoneostomies (15.1%) and three reimplantations on Boari flap bladder (4.1%). • The median follow-up was 87 months. RESULTS: • Tumours were pTa in 42.5% of patients, pT1 in 31.5%, pT2 in 17.8% and pT3 in 8.2%. • Recurrence of bladder urothelial carcinoma was found in 10 patients (13.7%) after a median time of 28 months. • The bladder recurrence-free survival at 5 years was 82.2%. • The overall survival at 5 years was 85.3% and the cancer-specific survival rate at 5 years was 94.1%. CONCLUSION: • Our data show that segmental ureterectomy procedures do not result in worse cancer control compared with data in the literature regarding nephroureterectomy.

Minimally invasive laparoscopic neobladder.

PURPOSE: To our knowledge orthotopic reconstruction after laparoscopic radical cystectomy has not been described in the human. After anatomical and surgical studies on cadavers we developed an original technique and performed the first laparoscopic radical cystectomy with pelvic lymphadenectomy and ileal orthotopic neobladder reconstruction in a patient. MATERIALS AND METHODS: Our technique has 3 steps, namely laparoscopic pelvic clearance, external reconstruction and laparoscopic reconstruction. After cystoprostatectomy and lymphadenectomy were completed via laparoscopy we removed the surgical specimens through a 5 cm. supraumbilical incision. Through the same incision an ileal loop was extracted from the abdominal cavity, isolated, detubularized and partially reconfigured. Intestinal continuity was restored extracorporeally. All intestinal loops were inserted back into the abdomen and pneumoperitoneum was started again. The ureteroileal (nipple valve) and urethroileal anastomoses were formed via laparoscopy and the neobladder was then completed with an intracorporeal running suture. RESULTS: Operative time was 450 minutes and blood loss was 350 ml. Postoperatively pain was minimal. The patient was ambulatory, regained bowel activity on postoperative day 2 and began food intake 2 days later. He was discharged home on postoperative day 7 with an indwelling catheter, which was removed after 7 days. Histopathological examination showed organ confined bladder cancer without margin invasion. CONCLUSIONS: To our knowledge we report the first case of laparoscopic radical cystectomy with ileal orthotopic reconstruction. This original technique combines the advantages of minimally invasive laparoscopy with the speed and safety of open surgery.

Comparison of single preoperative oral rufloxacin versus perioperative ciprofloxacin as prophylactic agents in transurethral surgery.

The aim of this prospective clinical trial was to compare the efficacy of rufloxacin, a once-daily fluoroquinolone administered as a single pre-operative dose versus the perioperative prophylaxis with ciprofloxacin in transurethral surgery. Two hundred and two patients undergoing transurethral resection of bladder tumors (132) or transurethral resection of the prostate (70) were selected for the study between January 1997 and June 1998. Patients were randomized to two treatment groups. Group A received a single oral 200 mg dose of rufloxacin three hours before surgery and group B was administered oral ciprofloxacin 250 mg bid until catheter removal. The two treatment groups were homogeneous with respect to patient characteristics. One hundred and seventy-three patients (89 rufloxacin and 84 ciprofloxacin) were assessed and 29 were excluded from the statistical analysis. The incidence of postoperative infection was similar in both treatment groups (5.7% rufloxacin, 4.7% ciprofloxacin). On the other hand, single-dose pre-operative prophylaxis with rufloxacin significantly reduced the cost of antibiotic prophylaxis. Results of the present study show that single dose oral rufloxacin may be used in routine clinical practice as a preoperative prophylactic antibiotic due to its low cost, its documented efficacy and its simple once daily dosage regimen.

[Transrectal ultrasound-guided biopsy of the prostate]. / Biopsia prostatica ecoguidata con accesso transrettale.

The early detection of prostatic neoplasm is nowadays a primary need in the urological field. The availability of transrectal ultrasound equipment alongside with bioptic tools made possible that transrectal ultrasound-guided biopsy of the prostate became the standard procedure to achieve this goal. With this work we would like to confirm the efficacy of this method which is also associated with a good tolerance and low complications rate. 82 patients that came to our Department between 1997 and 1999 were submitted to this procedure, 25 resulted positive for prostatic adenocarcinoma. Only 2 of them did not tolerate the procedure while all the others referred only mild discomfort at the moment of the puncture; 9 patients afterwards had to be admitted to the hospital due to fever (1 patient), acute retention of urine (3 patients) and persistent macroscopic hematuria (5 patients). Transrectal ultrasound-guided biopsy of the prostate reveals to be a safe and accurate method to obtain tissue samples of the prostate along with high tolerance and low incidence of serious complications.

Changes of renal resistive index in response to hydration and diuretic administration in normal subjects and in patients with small ureteral stone.

The renal resistive index has been measured before and after hydration and administration of diuretics in persons with normal kidneys and in kidneys with small ureteral stone, either obstructing or nonobstructing, to assess induced flow changes and to identify features differentiating obstructing from nonobstructing stones. In normal kidneys the resistive index was normal (mean, 0.62+/-0.03); no changes in the resistive index occurred within 15 to 60 min after hydration alone, whereas the resistive index rose within 15 min after hydration plus administration of diuretics and then returned to initial values within 30 min. In both cases the resistive index decreased below basal values after 75 to 90 min. Similar changes were observed in kidneys with a nonobstructing ureteral stone. In kidneys with an obstructing ureteral stone the resistive index was higher than in normal subjects (mean, 0.73+/-0.02, P<0.01), increased further within 15 min after hydration and administration of diuretics (P<0.01), and remained higher than basal values during the following 90 min. In conclusion, different resistive index changes have been observed in response to hydration and diuretics in normal and obstructed kidneys. Duplex Doppler sonography and diuresis duplex Doppler sonography seem promising diagnostic tools to identify obstructing stones.

The usefulness of the somatosensory evoked potentials of the pudendal nerve in diagnosis of probable multiple sclerosis.

STUDY DESIGN: The aim of the study was to evaluate the sensitivity of pSEP in patients affected by probable MS. OBJECTIVES: Bladder dysfunction is the presenting symptom in 2% of patients affected by multiple sclerosis (MS) and may be present in up to 78% of them. Abnormalities of somatosensory evoked potentials of the pudendal nerve (pSEP) have been found by many authors in patients affected by clinically defined MS, but little is known of diagnostic reliability of pSEP in early stage of MS. METHODS: Sixteen patients, eleven females and five males, aged between 18 and 45 years old (mean age 28.9), affected by clinically probable MS, were studied. Six of them reported retention or urge incontinence. pSEP with P1 (P40) scalp wave was analyzed. All patients also underwent visual evoked potentials (VEP), SEP of median and tibial nerves (mSEP, tSEP), brainstem acoustic evoked potentials (BAEPs), MRI of the brain and cerebrospinal fluid (CSF) evaluation. Urodynamic study with simultaneous measurement of intravesical, intraurethral and abdominal pressures with external sphincter electromyography was performed. RESULTS: Abnormalities of the evoked potentials were found in all patients. Abnormalities of the pSEP were observed in all the symptomatic cases and in eight of the remaining ten patients; ten showed no responses from the scalp and four showed P1 increased latency. Urodynamic abnormalities were found in 12 patients and MRI showed demyelinating lesions in 13 patients and oligoclonal bands were found in eight of them. CONCLUSION: pSEP can be worthwhile as part of the initial diagnostic evaluation in patients affected by MS. It provides information of diagnostic relevance and plays a role in screening patients for urodynamic testing, which, however, is more specific for detecting urethrovesical dysfunctions and preventing urological complications.

Embryonal adenoma of the kidney. A rare embryonal adenoma of the kidney.

We report the case of a 47-year-old man who underwent partial nephrectomy for an embryonal adenoma which was characterized by a monomorphous appearance. No adjuvant therapy was given and at the 5-year follow-up the patient is in perfect health and no relapse has been observed.

EGFr and c-erB2mRNA expression in urinary bladder superficial carcinomas.

AIM: The biological behaviour of superficial type transitional carcinomas of the urinary bladder can not be predicted. To try to differentiate those tumors that will present aggressive behaviour with infiltrative recurrences from those that will not, we studied, at the mRNA level, the expression of two membrane proteins, EGFr and c-erbB2, and of k-ras oncogene. METHODS: The mRNAs relative quantitation as performed, after RT-PCR, from histological sections cut from formalin-fixed and paraffin-embedded tissues. Twenty-three patients with urinary bladder transitional carcinoma have been studied for EGF-receptor, c-erbB2 and k-ras oncogene. The expression has been correlated with the outcomes of the follow-up period (infiltrative or superficial recurrences). RESULTS: The mRNA or EGFr was in average more expressed in tumors that continue to be superficial in the relapses, but for c-erbB2 the level of mRNA was similar in both, the more and less aggressive groups. The expression of k-ras was higher in cases associated with more infiltrative tumor relapses. CONCLUSIONS: In this preliminary study we did not identify any specific marker that can clearly predict the prognosis of superficial type transitional carcinoma of the urinary bladder; only k-ras expression is connected in some cases with the aggressiveness of the tumors. The expression of EGFr gave us intriguing results, it is in fact higher in the superficial carcinomas that do not tend to become infiltrative of the urinary bladder wall.

[Infrequent application of intraoperative ultrasonography in urology]. / Applicazioni infrequenti dell'ultrasonografia intraoperatoria in urologia.

Among the usual indications of intraoperative ultrasounds, we describe four infrequent applications that show how useful and powerful this technique could be for interventive urologists. The first case regards a 66 years old male who was affected by a renal metastasis from thoracic cage chondrosarcoma. The use of intraoperative ultrasounds permits to highlight atypical sonographic features of the secondary lesion that were not seen in preoperative radiologic exams and that are completely different from the usual renal lesions. The second case regards the treatment of prostatic abscess performed by echoguided transperineal puncture in which the use of transrectal ultrasound probe permits a precise and correct placement of the needle and the drainage in order to obtain a fast relief of the symptomatology. The third case shows the role of intraoperative ultrasounds in the localization of a parathyroid adenoma in a 52 years old male affected by primary hyperparathyroidism and with recurrent renal colics. In this case the blind surgical exploration of the parathyroid gland and so the possibility of iatrogenic lesions to the recurrent laryngeal nerve were avoided by the use of the intraoperative sonography for the identification of the adenoma. At the same time the operation times were reduced. The last case underlines the importance of using intraoperative ultrasounds in the real-time monitoring for the creation of the neovagina in sex reassignment surgery in male-to-female transexualism in order to avoid a dangerous postoperative complication represented by the iatrogenic lesion of the rectum during the dissection of the perineal region.